Hepatic trisegmentectomy and other liver resections

Abstract

THE FIRST to successfully remove all of the liver located to the right of the falciform ligament, or about 80 to 85 per cent of the organ, were Wangensteen (19), Lortat-Jacob and Robert (11) and Quattlebaum (17). The potential enthusiasm for the procedure which became known as extended right hepatic lobectomy was apparently dampened by a heavy mortality rate in the early trials of its use by Brunschwig (1) and by others. Although Pack and Molander (16) and Miller (14) acquired experience with more than 40 patients in the ensuing two decades, large collections were not reported by others. More recent series of hepatic resections have contained few extended right lobectomies. For example, Longmire and his associates (10) had only two in their experience with 75 hepatic resections. There were no such operations among the 107 hepatic resections recently reported by Lin (8).The literature concerning extended right hepatic lobectomy has added little about the surgical technique since the original descriptions. It is our purpose to focus upon a neglected aspect of the operation which concerns the anatomy encountered in dissecting the left branches of the portal triad toward the falciform ligament and umbilical fissure. At the same time, other principles of extended right lobectomy will be reviewed; their relevance to less extensive partial hepatectomies will be mentioned. SURGICAL UNITSThe basis for orderly subtotal resection of the liver is found in anatomic studies which were published a quarter of a century apart. The first of these influential reports was by McIndoe and Counseller (13) in 1927. They proved that the division between the true right and left lobes of the liver was not at the falciform ligament as had been previously believed but rather at a line going through the bed of the gallbladder and projecting posteriorly toward the vena cava. From 1950 to 1954, Hortsjö (7), Healey (5) and Healey and Schroy (6) demonstrated that each true lobe was further divided into two segments. The portal venous, hepatic arterial and hepatic duct branches conformed to the four segment organization. These observations were confirmed and extended by Couinaud (2) and Goldsmith and Woodburne (4). The larger hepatic veins were distributed differently since a number of their ramifications are between rather than within segments and lobes.For practical purposes, there are only four surgical units that lend themselves to controlled excision (Fig. 1) including the right and left true lobes which consist of two segments each. The third possibility is removal of the complete right lobe plus the medial segment of the left lobe. The operation is most correctly called trisegmentectomy, although the term of Pack and his associates (15) of extended right hepatic lobectomy has been frequently used. Fourth, the

Liver Resection for Hilar and Peripheral Cholangiocarcinomas: A Study of 62 Cases

“…Vascular reconstruction and excision of the hepatic parenchyma were used when indicated. The liver resections comprised nine right trisegmentectomies (R T -T), one left trisegmentectomy (LT-T), two right lobectomies (RT-L), one extended right lobectomy (Ext-RT), seven left lobectomies (LT-L), seven extended left lobectomies (Ext-LT) and one central excision (CE) (22)(23)(24)(25). [ See Table ill] .…”

“…[ See Table ill] . Excision of the caudate lobe was done in 20 of the 28 (71 %) patients (10,(22)(23)(24). Systematic lymph node dissection was done in 24 (86%) patients (10,12,26,27).…”

Treatment of Hilar Cholangiocarcinoma (Klatskin Tumors) with Hepatic Resection or Transplantation

“…Only two patients received central resection, and the remaining 32 patients received lobectomy or more extensive resection with techniques that have been described elsewhere. [14][15][16] The portal vein was resected with the tumor and was reconstructed in five patients, the hepatic artery was reconstructed in three patients, and both in one patient. All 3 portions of the caudate lobe were removed in 22 patients and 1 or 2 portions were resected in 12 patients.…”

Liver Resection for Hepatic Adenoma

“…27 There was no mortality, no serious morbidity, and there is no known recurrence of tumor. At the present time, formal anatomic resection of the benign hepatic adenoma is recommended as the preferred treatment, regardless of the manner of presentation of this tumor, when such resection can be carried out without mortality or significant morbidity.…”